Fillable Authorization To Release Information 1 (City of Galena)

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Authorization To Release Information 1 (City of Galena)

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Country of origin: US
File type: PDF

U.S.A. forms for City of Galena

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GALENA, KANSAS POLICE DEPARTMENT
AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCEREN:
I do hereby request and authorize you to furnish the Galena, Kansas Police Department
with any and all information they may request concerning my work record, educational history,
military record, financial and credit status, criminal record, driving record, general reputation and
disciplinary action. This authorization is specifically intended to include any and all information
of a confidential or privileged nature, as well as photocopies of such documents, if requested.
The information will be used for the purpose of determining my eligibility for a position with the
Galena Police Department.
I hereby release you and your organization from any liability which would result from
furnishing the information requested above or from any subsequent use of such information in
determining my eligibility for a position with the Galena, Kansas Police Department.
I also understand and agree to any and all interviews which may be deemed necessary by
the Galena, Kansas Police Department during the course of this investigation.
It is understood that this authorization shall be null and void after:
(Date) (Name) Type or Print)
(Signature) (Social Security Number)
(Witness) (Date)
WAIVER OF PRIVACY RIGHTS
I hereby waive any and all privacy rights I might have with respect to any information deemed
appropriate either in connection with my application or employment or the background
investigation which I acknowledge will be conducted by the Galena, Kansas Police Department.
(Signature) (Date)
(Witness)
CLEAR
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Authorization To Release Information 1 (City of Galena)

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Completed 14 July 2020

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